Endoscopy in asymptomatic minidose aspirin consumers.

Aspirin is widely used for its antiplatelet activity, but it harbors a risk of severe adverse gastrointestinal effects, such as bleeding and perforation, especially in elderly people. Our aim to assess the prevalence of upper gastrointestinal lesions and the effect of aspirin on the gastrointestinal mucosa in asymptomatic subjects taking minidose aspirin (100 to 325 mg per day) for more than 3 months. A prospective, open design was used. Patients attending the ophthalmology and cardiology outpatient clinics who had a medical history of more than 3 months of regular aspirin consumption were referred for esophagogastroduodenoscopy (EGD). Of the 90 patients referred for EGD, 44 were symptomatic (epigastric pain or dyspepsia) and were excluded from the study. The 46 asymptomatic patients included 22 men and 24 women of mean age 70 +/- 10 years (range, 36 to 87 years); 32% were current or former smokers. Mean daily aspirin dose was 129.34 +/- 76.61 mg. Only 24% were taking a gastroprotective agent. EGD revealed ulcer or erosions in 47.83% of the patients: erosive gastroduodenitis in 13 patients, gastric ulcer in 14, duodenal ulcer in 2, and gastric and duodenal ulcers in 2. Urease test for Helicobacter pylori infection was positive in 26%. Univariate and multivariate analysis revealed no factor other than aspirin predictive of a positive endoscopy. Minidose aspirin treatment is associated with a high prevalence of ulcerations of the stomach and duodenum.

Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for long-term enteral nutrition. Though safe and technically simple, PEG has been associated with significant morbidity and mortality. AIM: We compared the outcome of strategies applied in two different periods; the original approach of PEG insertion during hospitalization (upon request), and PEG insertion 30 days after hospital discharge. METHODS: A cohort of 127 patients scheduled for PEG insertion from 1.1.1997 to 31.12.2000, was evaluated. In 61 consecutive patients admitted from 1.1.1997 to 31.12.1998 the PEG insertion was planned during hospitalization, as close to the time of the physician's request (period 1). Sixty-six consecutive patients admitted from 1.1.1999 to 31.12.2000 were scheduled for the PEG insertion 30 days after discharge (period 2). The 30-day mortality rate was calculated from the time of the request. Univariate and multivariate analyses were used to find predictive factors for 30-day mortality. RESULTS: There were 61 patients with a mean age of 78+/-13 in period 1, and 66 patients with a mean age of 77.8+/-15.5 in period 2. There was no significant difference between patients of the two periods in regard to age, sex, underlying disease, nutritional and mental status. Patients received PEG 30 days after hospital discharge had a 40% lower 30-day mortality rate than patients who received PEG during hospitalization from the time of request for PEG (P=0.01) and a 87.5% lower rate when calculated from the time of insertion (P<0.0001). In-hospital PEG insertion, bed-ridden and disorientation were found to be independent factors predictive of 30-day mortality after PEG insertion (P=0.016,P=0.001, and P=0.0005, respectively). CONCLUSION: PEG insertion during hospitalization increases mortality and should be avoided. A grace period of 30 days with nasogastric tube feeding before PEG insertion may prevent mortality and achieve a long-term enteral nutrition.

Dyspepsia symptoms and Helicobacter pylori infection, Nakuru, Kenya.

The prevalence of Helicobacter pylori infection was studied in 138 patients with dyspepsia in a hospital in Nakuru, Kenya, and in 138 asymptomatic sex- and age-matched controls from the same population. Anti-H. pylori immunoglobulin (Ig) G was more prevalent in dyspeptic than asymptomatic persons (71% vs. 51%), particularly those <30 years old (71% vs. 38%). H. pylori seropositivity was associated with dyspepsia after adjusting for age, sex, and residence (urban or rural). Among adults, the association between H. pylori infection and dyspepsia remained after adjusting for the above factors and for educational attainment, family size, and manual occupation. H. pylori infection in asymptomatic residents of Nakuru, Kenya, was more prevalent in older persons, with a rate of 68%, than in those 31-40 years of age. However, young persons with dyspepsia had an unexpectedly high prevalence of H. pylori infection. H. pylori test-and-treat strategy should be considered in Kenyan patients with dyspepsia, particularly in persons <30 years of age.

13C-urea breath test, referral patterns, and results in children.

BACKGROUND: The family is the core unit for Helicobacter pylori (Hp) infection. In most instances, Hp colonization occurs in early childhood, and correlates with socioeconomic parameters. Helicobacter pylori infection is highly prevalent in many countries, and may cause chronic gastritis and peptic ulcer in adults and in children. Gastritis induced by Hp may be associated with recurrent abdominal pain in children, and eradication of the bacterium may improve the clinical symptoms. AIM The primary aim of this study is to characterize the group of pediatric patients according to the referral patterns and results of 13C-urea breath test (13C -UBT) in our laboratory. The secondary aim is to investigate the result of different treatment combinations for Hp eradication. METHODS: The 13C-UBT was performed with 75 mg urea labeled with 13C in 200 mL orange juice. Breath samples were collected at 0 and 30 minutes, and the results expressed as the change in the 13C/12C ratio at T30' minus T0' The cutoff for Hp eradication was 3.5. The physicians who ordered the test completed a questionnaire covering demographic data (age, gender, and origin), indication for the test was use of a proton pump inhibitor (PPI), and type of combination eradication therapy. RESULTS: The study sample consisted of 1655 children, aged 1 to 18 years, 992 (59.9%) boys and 663 (40.1%) girls, from all parts of the country. The 13C-UBT was positive in 763 (46.1%). The prevalence of positive results was directly correlated with age. History of peptic disease was the main indication for the test, in 1346 (81.4%) cases. Details on eradication therapy were available for 435 children of whom 42.5% had a positive 13C-UBT, indicating a successful eradication rate of 57.5%. Compared with Israeli and American-European origin, children of Asian-African origin had a higher rate of referrals for reason of validation of successful Hp eradication, greater long-term PPI use, and a higher rate of 13C-UBT positivity. No significant difference was demonstrated between the triple therapy regimens used. CONCLUSION: 13C-UBT may be performed in children of all age groups. The main indication is a history of peptic ulcer disease. The prevalence of Hp infection increased with age and the only factor associated with increased Hp infection was Asian-African origin. The most frequent eradication therapy used in children is a combination of omeprazole, amoxicillin, and clarithromycin.

13C-urea breath test to validate eradication of Helicobacter pylori in an Israeli population.

BACKGROUND: The 13C-urea breath test is the best non-invasive test to validate Helicobacter pylori eradication. Serology is unreliable for this purpose due to the slow and unpredictable decline in the antibody titer. OBJECTIVES: To characterize a specific group of patients who were treated for H. pylori and tested for successful eradication by 13C-UBT in our central laboratory, to correlate the eradication success rate with specific drug combinations, and to evaluate other factors that may influence eradication success. METHODS: 13C-UBT for H. pylori was performed in the central laboratory of Clalit Health Services. The breath test was performed by dedicated nurses in 25 regional laboratories and the samples were analyzed by a mass spectrometer (Analytical Precision 2003, UK). The physician who ordered the test completed a questionnaire computing demographic data (age, gender, origin), indication, use of non-steroidal anti-inflammatory drugs or proton pump inhibitor, and combination of eradication therapy. RESULTS: Of the 1,986 patients tested to validate successful H. pylori eradication, 539 (27%) had a positive test (treatment failure group) and 1,447 (73%) had a negative test (successful treatment group). Male gender, older age and European-American origin predicted better eradication rates. Dyspeptic symptoms and chronic PPI therapy predicted treatment failure. Combination therapy that included clarithromycin had a higher eradication rate than a combination containing metronidazole. The combination of omeprazole, amoxicillin and clarithromycin achieved an eradication rate of 81.3%, which was better than the combination of omeprazole, metronidazole and clarithromycin (77.2%) (not significant), or of omeprazole, amoxicillin and metronidazole (66.1%) (P < 0.01). CONCLUSION: Gender, age, origin, dyspepsia and PPI therapy may predict H. pylori eradication results. Our findings also support an increase in metronidazole resistance of H. pylori strains in Israel, as reported in other countries. We recommend combination therapy with omeprazole, amoxicillin and clarithromycin and avoidance of metronidazole as one of the first-line eradication drugs.

Case-control study of screening colonoscopy in relatives of patients with colorectal cancer.

OBJECTIVES: The efficacy of colonoscopic screening and polypectomy for the prevention of colorectal cancer (CRC) is well accepted but has never been documented in a prospective, controlled study. Screening by sigmoidoscopy has been found to reduce mortality from cancer of the rectum and distal colon. Case-control studies provide an alternative method for determining the efficacy of screening methods. METHODS: Between 1998 and 2000, a total of 40 subjects were found to have CRC (study group) and 160 had a normal colon (control group) among asymptomatic individuals participating in a screening colonoscopy program for a high-risk population of first-degree relatives of CRC patients. We compared these groups for screening by fecal occult blood testing, flexible sigmoidoscopy, barium enema, and colonoscopy in the 10-yr period before the index colonoscopy. RESULTS: Screening colonoscopy was performed in only 2.5% of the case subjects and 48.7% of controls (p < 0.0001), and all screening procedures in 12.5% and 73.7%, respectively (p < 0.0001). A statistically significant difference was also found for screening with fecal occult blood test, but not for flexible sigmoidoscopy or barium enema. Significant adenomatous polyps >1 cm in diameter were detected and removed in 19% of the control group within 10 yr of the index colonoscopy. Six (15%) of the patients in the study group died of CRC. CONCLUSIONS: Screening by colonoscopy can prevent progression to CRC from adenomatous polyps and may reduce the mortality associated with this devastating disease.

Survey of the opinions, knowledge and practices of surgeons and internists regarding Helicobacter pylori test-and-treat policy.

BACKGROUND: Helicobacter pylori infection is highly prevalent and may cause disease in 10% to 15% of infected individuals: duodenal and gastric ulcer, gastric cancer and gastric lymphoma. Guidelines for a test-and-treat policy have been published by the European H. pylori working group in Maastricht. GOALS: To assess the current approach to H. pylori-related diseases, indications for testing and eradication therapy, among internists and surgeons of a University affiliated medical center. STUDY: A 15-items questionnaire was formulated according to the Maastricht II test-and-treat recommendation and distributed among the physicians of 6 internal medicine departments and the department of surgery. The questionnaires were completed anonymously at the department's staff meeting, under the supervision of the head of the department. All questions required a yes/no answer; the maximum possible score was 15. The relative ratio (RR) of correct answers was calculated for every question and by subgroups as follows: all participants, internists, surgeons, experts and residents in internal medicine and surgery. RESULTS: The response rate was 68% (55 out of 80 physicians). Total score for all participants was 10.9 (RR = 0.73), significantly lower than the maximum score of 15 (RR = 1.00). The internists had significantly higher average score than the surgeons for 2 questions: causative agent in gastric cancer (p = 0.003) or gastric lymphoma (p = 0.003), 1 question about triple therapy, PPI, penicillin and azythromycin being not recommended (p = 0.022), and for 1 question of test-and-treat policy: should this strategy apply to family members of gastric cancer patients (p = 0.045). Only 56% of the internists and 21% of surgeons knew what MALToma is, and the correlation with H. pylori infection. CONCLUSION: Knowledge of Surgeons and Internists regarding infection and correlation with diseases or test and treat policy should be improved.

Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects.

Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion.